Neurology & Pain Management Coding Alert

(Editors note: This is part two of a two-part article. The first section can be found in the February issue of Neurology Coding Alert.)

Neurology coders need to understand when it is appropriate to code signs and symptoms rather than the final diagnosis for an EEG study so that significant reimbursement is not lost. Additionally, by learning when it is and is not appropriate to bill for digital analysis, audits and costly paybacks can be avoided.

Symptom-based ICD-9 Coding

If a person is referred to my lab with a question of rule-out seizures and the EEG is normal, payment for it may be denied by the insurance company because they dont accept the rule-out diagnosis, says Larry Seiden, MD, assistant professor of neurology and director of the University of Maryland Center for Sleep Disorders.

For example, a referring primary care physician (PCP) believes a patients signs and symptoms may be indicative of seizures, but not likely. If this possibility was not investigated and the patient later turned out to have seizures, the PCP may have been at a malpractice risk. To cover his or her bases, he or she refers the patient to Seiden to rule it out. Medicare and most third-party payers will not cover tests linked to a diagnosis that is unconfirmed due to concerns about unnecessary testing. For this reason, Seiden recommends coding the EEG based on the symptoms that first caused concern, not the unconfirmed possible diagnoses of seizures.

In another example, a patient complains of blackouts (fainting spells). The neurologist believes they may be the result of seizures but, to test for this, performs an EEG. Because a possible or rule-out diagnosis of seizures will lead to a denial, the neurologist codes for the symptoms of either fainting spells (780.2) or brief loss of consciousness (780.09) along with 95819 for the awake and asleep EEG.

Medicare will deny unspecified diagnosis codes because they do not provide the medical necessity for the EEG, warns Erwin Montgomery, MD, director of the movement disorders program for the Cleveland Clinic in Cleveland, which has more than 40 neurologists on staff.

For example, a patient presents with memory loss, and the neurologist runs an EEG. If 780.9 (other general symptoms including amnesia [retrograde], chill[s], generalized pain, hypothermia, etc.) is used as the diagnosis linked to the procedure, insurance companies may not pay because the diagnosis definition, while including amnesia, also lists many unrelated conditions. Such diagnoses are generally not on a carriers list that denotes medical necessity. The coder should choose another one that also describes the problem, such as organic brain syndrome (310.9), which is normally covered. Montgomery says the neurologist should contact his or her local Medicare carrier and ask what justifies medical necessity. Such information can also be found by searching for local carrier policies.

Note: HCFA regulations state that assigning diagnosis codes for symptoms is appropriate and acceptable for physician reporting when the final diagnosis is not definite.

Long-term Monitoring

Denials for long-term monitoring (95950-95951, 95953, 95956) usually occur due to the lack of documentation that conventional EEG studies (95816, 95819, 95822, 95827) were first performed (as per Medicare and most third-party payer guidelines), Montgomery says. Carrier policies state that these studies must be seizure-focus in nature, meaning they are performed to track and analyze brain seizures. This must also be noted in the patient chart and any documentation.

Only 95951 (monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic [EEG] and video recording and interpretation [e.g., for presurgical localization], each 24 hours) can be used for presurgical localization of a seizure focus.

For example, a neurology patient suffers from extended convulsive seizures, also called status epilepticus (345.3), which requires surgery. To find the exact location in the brain where the seizures originate, the neurologist uses this study. It would be coded:

95951 for the EEG presurgical seizure focus localization, long-term monitoring
345.3 for the diagnosis of status epilepticus

Because these codes describe distinct methods of monitoring, more than one can be used during the same study. In this case, different codes within this range can be billed together. In addition, the same one may be reported twice with modifier -51 (multiple procedures) if the study exceeds 24 hours. If monitoring is less than 24 hours, coders should bill the appropriate code with modifier -52 (reduced services) and indicate in the report the duration of the study.

Digital Analysis of EEG

Neurology coders who inappropriately bill 95957 (digital analysis of electroencephalogram [EEG] [e.g., for epileptic spike analysis]) may see added reimbursement initially, then face demands for large paybacks and increased scrutiny during and after audits for all billing practices, says Marc R. Nuwer, MD, PhD, a professor of neurology at UCLA, and president of the International Federation of Clinical Neurophysiology, 1997-2001.

Nuwer, who is also a CPT advisor for the American Academy of Neurology, says the confusion stems from the incorrect belief that the use of a digital EEG machine automatically results in a digital analysis. While it is true that only a digital machine may yield the data used to create an analysis report, the technician spends an additional hour processing that information. The neurologist then spends an extra 20 to 30 minutes reviewing the report.

If a practice that routinely bills for and gains reimbursement for digital analysis is audited, and a record of the additional work performed is not in the corresponding patient records, carriers will demand refunds.

Nuwer says most neurologists do not have the opportunity to perform this additional work. Digital analysis is more commonly used at specialty centers (e.g., epilepsy surgery programs).

Coders often bill the digital analysis code with inappropriate EEG procedures and face denials because there is no instruction about this following 95957. Nor is there any mention of digital analysis after the majority of EEG codes. However, there are notations after 95819 and 95954 (pharmacological or physical activation requiring physician attendance during EEG recording of activation phase [e.g., thiopental activation test]) that digital analysis may be billed with them. Coders often overlook this information and bill incorrectly.

An example of proper billing follows:

95819 for the EEG awake and asleep
95957 for the digital analysis
345.11 for the diagnosis of seizures